Home Visit APRN/PA Naples

M&H Housecalls · United States

Location: Naples, FL Schedule: Flexible 4 days a week/ 1099 Job Summary: As a "Home Visit APRN or PA" you will function as a day-to-day clinical leader, providing support and care during patient transitions from acute to home: directing the multidisciplinary team. Primary Functions:

• Perform 6-10 preventive visits daily to optimize chronic conditions, assess home environment, educate patients and caregivers, and develop proactive care plans.
• Perform timely new care visits and follow up care as needed in the home, while our focus is to avoid unnecessary ED transfers and hospital admissions.
• In situations where there is no existing PCP for the patient, assume responsibility as interim provider and drive care and continuity for patients.
• In situations where there is an existing PCP for the patient, help to co-manage the patient with the PCP and serve as an extension of clinical care into the home.
• Coordinate with other physicians across the continuum of care, including PCP, hospitalist, and SNF providers to smooth transitions and prevent readmissions.
• Coordinate and offer medical direction to community-based organizations touching the lives of our patients, including housing and caregiver agencies, health plan contracted social work services, home health, adult day health centers, and behavioral health.